EmailMeForm
ECEAP/Child Development Center Pre-Enrollment Form
Please provide the following information about your child, family, and household.
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Child Information
Please enter information about your child(ren) below.
Child's Name
*
First
Last
Child's Birthdate
*
MM
/
DD
/
YYYY
Child's Gender
Male
Female
Child's First Language
*
Child's Second Language
Does this child need transportation to attend school?
*
Yes
No
What days and hours is child care needed?
Do you qualify for Working Connections Childcare benefits?
*
Yes
No
Maybe
Child's Doctor
*
Child's Dentist
*
Health/Dental Insurance Provider
*
Please list any medical conditions
*
Please list any known allergies
*
Does this child have an IFSP or IEP?
*
Yes
No
Does this child have a suspected delay?
*
Yes
No
Maybe
Is this child potty trained?
*
Yes
No
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